Information Collection

Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167

IC 7877 under ICR 200902-0938-006 · OMB 0938-0193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0193 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-179 Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167	Form and Instruction
CMS-179 Transmittal Notice of Approval of State Plan Material cms179.pdf	Form and Instruction
DCIS att 4 39A .doc DCIS att 4 39A	IC Document
DCIS att 4 39B .doc DCIS att 4 39B	IC Document
DCIS sec 4 39 PASRR.doc DCIS sec 4 39 PASRR	IC Document
DEH rev4 17 Liens Adj Rec p53 No Att.doc DEH rev4 17 Liens Adj Rec p53 No Att	IC Document
DEH rev4 22 Base Plan TPL p69,69a,70.doc DEH rev4 22 Base Plan TPL p69,69a,70	IC Document
DEH rev 2 PRA Base Plan Territory-Section2.doc DEH rev 2 PRA Base Plan Territory-Section2	IC Document
DEH rev PRA Base Plan PRA State-Section2.doc DEH rev PRA Base Plan PRA State-Section2	IC Document
DEH Section 3 pages PRA version 7 10 08.pdf DEH Section 3 pages PRA version 7 10 08	IC Document
DEH_State 2 6-A PRA (2).pdf DEH_State 2 6-A PRA (2)	IC Document
DEH_State 2.2-A PRA.doc DEH_State 2	IC Document
DEH_State-Section2 Base.doc DEH_State-Section2 Base	IC Document
DEH_Territory-2 2-A PRA508 .pdf DEH_Territory-2 2-A PRA508	IC Document
DEH_Territory-2 6-A PRA (2).pdf DEH_Territory-2 6-A PRA (2)	IC Document
DEH_Territory-Section2 Base.doc DEH_Territory-Section2 Base	IC Document
Exhibits for Base Plan PRA Pages.doc Exhibits for Base Plan PRA Pages	IC Document
FCH rev 431_434.doc FCH rev 431_434	IC Document
FMG rev4 19 b - DP Revision 07-17-08.doc FMG rev4 19 b - DP Revision 07-17-08	IC Document
FMG4 19b preprint 7-29-08.pdf FMG4 19b preprint 7-29-08	IC Document
FMG rev4 19 (k) page 66a.doc FMG rev4 19 (k) page 66a	IC Document
FMG rev4 19 Att 4 19-B sec 24p1a.DOC FMG rev4 19 Att 4 19-B sec 24p1a	IC Document
FMG rev4 19 B supp1 preprint.doc FMG rev4 19 B supp1 preprint	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Transmittal and Notice of Approval of State Plan Material and Supporting Regulations in 42 CFR 430.10-430.20 and 440.167

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 430.10 42 CFR 430.20 42 CFR 440.167

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-179	Transmittal Notice of Approval of State Plan Material	cms179.pdf		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,681	4,625	56
Annual IC Time Burden (Hours)	9,271	8,711	560
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DCIS att 4 39A	DCIS att 4 39A .doc	01/09/2009
DCIS att 4 39B	DCIS att 4 39B .doc	01/09/2009
DCIS sec 4 39 PASRR	DCIS sec 4 39 PASRR.doc	01/09/2009
DEH rev4 17 Liens Adj Rec p53 No Att	DEH rev4 17 Liens Adj Rec p53 No Att.doc	01/09/2009
DEH rev4 22 Base Plan TPL p69,69a,70	DEH rev4 22 Base Plan TPL p69,69a,70.doc	01/09/2009
DEH rev 2 PRA Base Plan Territory-Section2	DEH rev 2 PRA Base Plan Territory-Section2.doc	01/09/2009
DEH rev PRA Base Plan PRA State-Section2	DEH rev PRA Base Plan PRA State-Section2.doc	01/09/2009
DEH Section 3 pages PRA version 7 10 08	DEH Section 3 pages PRA version 7 10 08.pdf	01/09/2009
DEH_State 2 6-A PRA (2)	DEH_State 2 6-A PRA (2).pdf	01/09/2009
DEH_State 2	DEH_State 2.2-A PRA.doc	01/09/2009
DEH_State-Section2 Base	DEH_State-Section2 Base.doc	01/09/2009
DEH_Territory-2 2-A PRA508	DEH_Territory-2 2-A PRA508 .pdf	01/09/2009
DEH_Territory-2 6-A PRA (2)	DEH_Territory-2 6-A PRA (2).pdf	01/09/2009
DEH_Territory-Section2 Base	DEH_Territory-Section2 Base.doc	01/09/2009
Exhibits for Base Plan PRA Pages	Exhibits for Base Plan PRA Pages.doc	01/09/2009
FCH rev 431_434	FCH rev 431_434.doc	01/09/2009
FMG rev4 19 b - DP Revision 07-17-08	FMG rev4 19 b - DP Revision 07-17-08.doc	01/09/2009
FMG4 19b preprint 7-29-08	FMG4 19b preprint 7-29-08.pdf	01/09/2009
FMG rev4 19 (k) page 66a	FMG rev4 19 (k) page 66a.doc	01/09/2009
FMG rev4 19 Att 4 19-B sec 24p1a	FMG rev4 19 Att 4 19-B sec 24p1a.DOC	01/09/2009
FMG rev4 19 B supp1 preprint	FMG rev4 19 B supp1 preprint.doc	01/09/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.